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Not for Use in Middle East or Europe · 2020-04-08 · QROPS provider – pension transfers to the...

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1 of 13 Please tick appropriate circle (Acceptable applicant) QROPS Trustees (3) (Acceptable applicant) SIPP Trustees (3) (Acceptable applicant) QNUPS Trustees (3) Company QROPS (3) This document was last updated in August 2020. Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs. We only sell our products through financial advisers as we believe it is important you receive independent financial advice. The financial adviser is not acting as an agent for Quilter International. All references to Quilter International, we, us and our in this application form mean Quilter International Isle of Man Limited with the exception of the Trustee Declaration. Taxation information Under Automatic Exchange of Information (AEOI) regulations Quilter International is required to obtain information about an applicant’s tax status. To enable us to comply with these regulations, when submitting this application form you must also submit the ‘Taxation information and self-certification – for entity investors’ for corporate and trustee investments. Completion and submission of a self-certification is mandatory and failure to provide one could result in your Portfolio being reported under AEOI by default. If any of the information contained in the self-certification changes please advise Quilter International promptly so we can determine if a new self-certification is required. Important information Your application can be submitted online via Wealth Interactive. If you choose this option, your application can be submitted to us immediately without the delay that can be experienced through the postal system. This application form must not be used for Singapore business. A copy of the member’s application for a QROPS/ QNUPS/SIPP application form should accompany this form. A copy of your Executive Investment Bond, Executive Redemption Bond, Collective Investment Bond or Collective Redemption Bond Terms and Conditions are available on request. Starting or Adding to Your Quilter International Bond Not for Use in Middle East or Europe Customer ID number(s) If known please enter the Customer ID number(s) Applicant 1 Financial adviser details Quilter International account reference - Name of financial adviser Company name Address Telephone number Fax number E-mail address Quilter International only accepts business introduced by companies which have Terms of Business with us.
Transcript

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Please tick appropriate circle

(Acceptable applicant) QROPS Trustees (3)

(Acceptable applicant) SIPP Trustees (3)

(Acceptable applicant) QNUPS Trustees (3)

Company QROPS (3)

This document was last updated in August 2020. Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs.

We only sell our products through financial advisers as we believe it is important you receive independent financial advice. The financial adviser is not acting as an agent for Quilter International.

All references to Quilter International, we, us and our in this application form mean Quilter International Isle of Man Limited with the exception of the Trustee Declaration.

Taxation information

Under Automatic Exchange of Information (AEOI) regulations Quilter International is required to obtain information about an applicant’s tax status. To enable us to comply with these regulations, when submitting this application form you must also submit the ‘Taxation information and self-certification – for entity investors’ for corporate and trustee investments. Completion and submission of a self-certification is mandatory and failure to provide one could result in your Portfolio being reported under AEOI by default. If any of the information contained in the self-certification changes please advise Quilter International promptly so we can determine if a new self-certification is required.

Important information

Your application can be submitted online via Wealth Interactive. If you choose this option, your application can be submitted to us immediately without the delay that can be experienced through the postal system.

This application form must not be used for Singapore business. A copy of the member’s application for a QROPS/QNUPS/SIPP application form should accompany this form. A copy of your Executive Investment Bond, Executive Redemption Bond, Collective Investment Bond or Collective Redemption Bond Terms and Conditions are available on request.

Starting or Adding to Your Quilter International BondNot for Use in Middle East or Europe

Customer ID number(s) If known please enter the Customer ID number(s)

Applicant 1

Financial adviser details

Quilter International account reference

-

Name of financial adviser

Company name

Address

Telephone number

Fax number

E-mail address

Quilter International only accepts business introduced by companies which have Terms of Business with us.

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Note Key Information Document (KID)

A KID is a short document that describes the product’s key features and target market, as well as the cost of owning the product and the risks associated with investment. It allows you to make comparisons with similar products from Isle of Man Financial Services Authority authorised insurers.

Under the Isle of Man Financial Services Authority’s Insurance (Conduct of Business) (Long Term Business) Code 2018, Quilter International is required to provide you with a KID if you are applying for a new bond or adding to a bond that you started after 31 December 2017. Where it’s applicable, you should make sure you read your KID before completing this application. It can be obtained from your financial adviser.

If you are starting a new bond, you must sign and return the KID to Quilter International before we can accept your application.

If you are adding to an existing bond, you do not need to return the KID to us.

Online service account on wealth interactive

Where you have set up an Online Service Account, ongoing communication from us, such as policy valuations, will be carried out electronically through this account as much as possible, although there will be times when we do still need to correspond with you by letter.

If you would prefer to receive ongoing communication from us by post rather than online, please tick here (3)  

The underlying member may apply for a view only account. If this is required, please provide their email address.

Your right to cancel (applicable to the QROPS trustee, SIPP trustee, QNUPS trustee or company QROPS)

You have the right to cancel your Bond or additional investment and obtain a refund of any contribution(s) paid, less any applicable charges* and any fall in the value of the assets linked to your Bond. You have 30 days from the date that you receive the Schedule for the initial contribution, or letter accepting the additional investment to let us know you want to cancel. Further information on how to cancel can be found in the Bond Terms and Conditions.*Where relevant, applicable charges include non-refundable fund charges, fees we have paid to your financial adviser on your behalf and bank charges

Section A – Type of application

Completing the form

To complete this form:

– use CAPITAL LETTERS only – use blue or black ink – specify choices as appropriate – do not use correction fluid; any amendments should be crossed out and initialled by authorised signatories of the corporate

trustee or company signatories.Please ensure that you complete all relevant sections. We will contact you regarding any missing information which will need to be provided to us in writing, and this may delay your application.

New investment

The type of bond cannot be changed after it has been set up.

Please select one product from the selection below. (3)

Capital redemption bonds Life assurance bondsExecutive Redemption Bond (ERB) (Terms ref ERB4) Executive Investment Bond (EIB) (Terms ref EIB4)

Collective Redemption Bond (CRB) (Terms ref CRB5) Collective Investment Bond (CIB) (Terms ref CIB4)

Additional transfer

If this is an application for an additional transfer please provide your existing bond number:

We have used the term ‘bond’ to refer to your chosen Quilter International product throughout this application.

Bond currency

We wish our bond to be valued in (3)  £  US$  €  Othercurrency 

Please note if no currency is entered your bond currency will be pound sterling (£). The Bond currency cannot be changed after the Bond is set up.

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Appointment of an authorised custodian

Please tick if you wish to appoint an authorised custodian? (3)     Authorisedcustodian

Name of custodian

If you have ticked above, you need to complete the Request to transfer to an authorised custodian account form and a letter of authority which is available from your financial adviser.

Section B – Details of the applicant QROPS TRUSTEE (3)     QNUPS TRUSTEE (3)     SIPP (3)

Jurisdiction of trustees

The trust name is:

The trust was created on:

Trust details: Please explain the reason for the establishment of the trust, what type of trust it is and detail the source/origin of the trust assets.

QROPS provider – pension transfers to the QROPS (being the evidence of origin of the assets supplied by the QROPS Trustee).

QNUPS scheme to provide a pension in retirement. The trust assets will be a lump sum contribution to the QNUPS. (QNUPS Trustee will provide origin of assets evidence).

 Pensioncontributions(3)

 Pensiontransfers(3)

Trust assets

Corporate trustee name

Other trustees Member (3)

 Company QROPS (3)

Company name

Date of incorporation:D D M M Y Y Y Y

Country of registration

Contact person

Registered office address (This information must be provided in full. We are unable to accept PO Box and ‘care of’ addresses.)

Correspondence address

Telephone number including area codeE-mail address

Company website address

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Politically exposed person

If the applicant(s), or any other party connected to this application either now or in the past/future, could be classed as a politically exposed person (PEP), or connected with a PEP, please provide details.

A politically exposed person is someone holding an important public position, or a person clearly related to them. Examples of these are: judicial or military officials, senior politicians, senior executives of publicly owned corporations, senior Government officials and Important political officials.

Authorised signatories

Please confirm the minimum number of authorised signatories of the company/corporate trustee needed to give instructions

Section C – Details of the life assuredThis section should only be completed if you have selected a new life assured bond, eg the Executive Investment Bond or Collective Investment Bond in section A.

The maximum age for a life assured is 89.

First life assured (member) Second life assured (if any)

Title (3)  Mr   Mrs   Miss

 Other 

 Mr   Mrs   Miss

 Other 

Full forename(s)

Surname

Sex (3)  Male    Female  Male    Female

Date of birthD D M M Y Y Y Y D D M M Y Y Y Y

Nationality

Dual nationality (if applicable)

Residential Address (This is where life assured is currently living. Please note we do no accept c/o and PO Box addresses.)

Section D – Source of funding

Source of funds

  The premium payment must come from an account held in the name of the trust.

Scheme Account name Currency Sort code SWIFT code Account number IBAN number

QROPS

QNUPS

SIPP

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QROPS QNUPS SIPPBank name

Bank address

Country

When did the trust open this account?

Section E – Investment details

Premium payment

Currency (3) £  US$  €  Othercurrency 

Amount to be invested (anticipated total amount based upon estimated transfer value(s))Payment method (3)  Electronicbanktransfer    ShareTransfer

Where you have chosen an authorised custodian, are you remitting your premium to be paid: (3)

to Quilter International; orby cash transfer via the authorised custodian?

Section F – Asset choicePlease use this section to list the assets you wish to invest in. Please note if we do not receive sufficient details, this will delay your investment. You do not need to complete this section if you have appointed an authorised custodian in Section A.

Asset choice

Asset identifier SEDOL/ISIN

Security/Fund name – please enter names in full. If an Quilter International fund is chosen, please prefix the fund name with QINT IM.

Accumulation /Income unit requirement (if applicable)

Share class (if applicable, for example A, B or C)

Base currency of security/ fund (eg GBP, USD)

Investment % (whole % numbers only)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

TOTAL (must add up to 100%) 100%

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In case we need to clarify the asset choice details above, please provide us with a contact name and telephone number.

Contact name

Telephone number including area code (daytime)

Telephone number including area code (evening)

Fax number E-mail address

Section G – Origin of wealth

Full details of origin of wealth

Please tick the description option(s) relating to the original source of the premium for your policy. You must fully complete each relevant section relating to the description option(s) you have ticked.

This section must be completed in all instances

(3) Description Details required DetailsTransfer of pension Pension name

Pension account number

Pension value Currency:

Amount:

Transfer date D D M M Y Y Y Y

Transfer of pension Pension name

Pension account number

Pension value Currency:

Amount:

Transfer date D D M M Y Y Y Y

Transfer of pension Pension name

Pension account number

Pension value Currency:

Amount:

Transfer date D D M M Y Y Y Y

Transfer of pension Pension name

Pension account number

Pension value Currency:

Amount:

Transfer date D D M M Y Y Y Y

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Transfer of pension Pension name

Pension account number

Pension value Currency:

Amount:

Transfer date D D M M Y Y Y Y

Other Origin of wealth (if ticked Other)

From which organisation or whom (state the relationship if applicable)

Details (including reasons where applicable how the money was acquired etc)

Total amount Currency:

Amount:

Date received D D M M Y Y Y Y

  We may also require additional documentary evidence to support your application, particularly in relation to your country of residence and investment amount, before we can process it.

Please enter what documentary evidence you are enclosing with this application form (if applicable).

Section H – Regular withdrawals (optional)

Withdrawal amount

Amount to be withdrawn each year

orPercentage of premium to be withdrawn each year %

Withdrawal frequency (3)  Monthly    Every2months    Quarterly    Half-yearly    Yearly

Date of first paymentD D M M Y Y Y Y

If your plan is not active on the due date then your first payment will be made on the next payment date due according to the frequency chosen.

Where you have requested the appointment of an authorised custodian, do you want Quilter International to consider allowing the authorised custodian paying regular withdrawals on Quilter International’s behalf to you directly? please tick (3)

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Nominated asset(s)

Please state which asset(s) listed in Section E is/are to be used as the Nominated Asset to pay regular withdrawals. This will only apply where you have not chosen an authorised custodian.

Please note that you are required to keep a sufficient balance in your nominated asset to cover withdrawals debited to your policy. Therefore we are unable to pay any withdrawals if there is an insufficient balance in your nominated asset.

  If there are any further Nominated Assets, please photocopy this page, attach the details with this application form and tick here  

ISIN/SEDOL Name Percentage %

ISIN/SEDOL Name Percentage %

ISIN/SEDOL Name Percentage %

ISIN/SEDOL Name Percentage %

ISIN/SEDOL Name Percentage %

Payee details

All payments will be third party payments - ie to the underlying member.

Please select your preferred payment method:

 Telegraphic Transfer Please be advised that payments incur a bank transfer charge.

 BACS direct creditOnly available for GBP payments paid to a UK, IOM or Channel Islands bank account.This payment method takes three working days to reach the account, but doesn’t incur a bank transfer charge.

If no payment method is selected we will default to Telegraphic Transfer, unless you have requested GBP regular withdrawals payments, in which case we will default to BACS where possible.Do you want your withdrawals to be made to the same bank account detailed in Section D ‘Source of Funding’?  Yes  No

If “No” please complete your chosen bank details below.

Until further notice, I/we would like regular withdrawals to be made to:

Bank account holder (name as stated on bank account)

Bank account number/IBAN

Sort code (applicable to UK accounts) - -

SWIFT or BIC code

(SWIFT code needed for bank accounts outside Europe; BIC code needed for European accounts with an IBAN)

ABA number Branch code for non-UK banks

Bank name

Bank address

Postcode

Country

Please Note:

Haveyouselectedthewithdrawalamount,currency,withdrawal,frequencyandthedateofyourfirstpayment?

HaveyouNominatedAsset(s)tofundyourregularwithdrawals?

Haveyoucompletedthepayeedetails?

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Section I – Number of policies

Number of policies (new bonds only)

Please enter the number of policies you would like:

The number of policies cannot be changed after the Bond is set up.

  We normally issue 12 policy schedules per contract. If you require more or less, insert the number required.

Wheremoreschedulesarerequired,pleasenotethatfortheERB,theminimumpremiumperscheduleis£5000/€7500/$7000(or currency equivalent).

Section J – Fund adviser

Appointing a fund adviser to your Quilter International portfolio bond

Please tick as appropriate (3)

I have not appointed a Fund Adviser and I will act on an “execution only basis” (where I have requested the appointment of an Authorised Custodian in section A, I also include a completed ‘letter of authority’); or

I appoint a Fund Adviser and enclose a completed ‘appointing a fund adviser to your Quilter International Portfolio Bond’ form and, where the Fund Adviser is not linked to any Authorised Custodian I have requested to be appointed in section A, a ‘letter of authority’.

Section K – Charges and policy currencyThe charging structure for your bond is based upon the reference code provided on your application; this will dictate the level, term and type of charges that apply and these will be confirmed to you in your policy documents. These charges will include our administration costs together with those incurred in making any initial commission payment to your financial adviser.

If you have agreed to pay your financial adviser an ongoing commission payment (referred to as fund based commission) then this will be reflected in the deduction of an additional Ongoing Service Charge equivalent to the amount paid.

Charges

Please enter the reference code for your chosen charging structure which you confirm you have received and read in full. (Your financial adviser representative will be able to provide you with this code.)

Please enter allocation percentage for this bond % Please enter fund-based commission

(if applicable) %

Section L – Declaration and application

Data privacy statement

I understand that Quilter International Business Services, Quilter International Isle of Man Limited and/or Quilter International Ireland dac (Quilter International) will process personal information about me and any other party whose personal information I have provided.

The type of personal information processed about me will depend on the purpose for which it has been collected and will include: – my contact details – information to verify my identity – information about my family, lifestyle, health and finances – my payment details.

The processing of my personal information may take place in a number of jurisdictions and may be shared with other parties within or outside Quilter plc for the general purpose of establishing, maintaining and servicing an insurance policy.

The sharing of my personal data may be used for any or all of the following purposes, to: – check against credit reference or other databases to verify information provided for regulatory due diligence purposes and to

prevent or detect financial crime including money laundering, terrorist financing, bribery and corruption, sanctions listing or fraud;

– allow for the provision of services relating to enhanced due diligence, underwriting, reinsurance, data hosting, online services, payment or reporting of any tax or levy, or any other services provided from time to time;

– enable an appointed financial adviser or fund adviser to assist in the provision of services to the policyholder; – compile statistical analysis or market research, where information is not specific to the individual;

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– comply with any legal obligation which includes the releasing of personal information to regulators, law enforcement authori-ties or other bodies where there is a legal requirement to do so, including the sharing of information under regulations relating to the U.S Foreign Account Tax Compliance Act and The Organisation for Economic Co-operation and Development Common Reporting Standard;

– enable an appointed discretionary asset manager or custodian to meet their legal or regulatory requirements, where that discretionary asset manager or custodian providing services in relation to a policy requests the personal data of an individual linked to an application, and where we are satisfied that such a discretionary asset manager or custodian has a legal or regulatory requirement to make such a request.

Where my personal information is shared with a third party for the provision of services relating to my policy, my personal information will only be used for the purposes for which it was collected. In some circumstances this may involve a transfer of my personal information to a third party outside the European Economic Area (EEA). Whenever my personal information is shared it will be subject to the same levels of security and protection that Quilter International would apply.

I may ask Quilter International to: – provide a copy of personal information held about me and an explanation of how this data is processed; – update or correct my personal information; – delete information about me (where it is no longer necessary in relation to the purpose for which it was originally collected); – restrict processing of my personal information where appropriate. I may also object to Quilter International processing my

data but understand that this may have consequences in Quilter International being able to continue servicing my policy.I have been made aware that a full explanation of how Quilter International collects, uses and shares my personal information can be found at www.quilterinternational.com

If I have any questions about data privacy I can address these to:

For Quilter International Isle of Man Limited: The Data Protection Officer, Quilter International Isle of Man Limited, King EdwardBayHouse,KingEdwardRoad,Onchan,IsleofMan,BritishIsles,IM991NU.

For Quilter International Ireland dac:TheDataProtectionOfficer,QuilterInternationalIrelanddac,HambledenHouse,19-26Lower Pembroke Street, Dublin 2, D02 WV96, Ireland.

If I have a complaint about the processing of my personal information and Quilter International is unable to provide a satisfactory response I may contact the appropriate regulator:

For Quilter International Isle of Man Limited:TheIsleofManInformationCommissioner,FirstFloor,ProspectHill,Douglas,Isle of Man, IM1 1ET.

For Quilter International Ireland dac: TheIrelandDataProtectionCommissioner,CanalHouse,StationRoad,Portarlington,R32 AP23 Co. Laois, Ireland.

I have read and understood the Data Privacy Statement set out above and will make it available to other individuals whose personal information has been provided by me to Quilter International either in this application or within accompanying documentation.

Important information

Please read the following declaration carefully.

Any omission or misstatement of a material fact in this application could affect the payment of benefits under the policy. A material fact is one which is likely to influence the assessment and acceptance of the application.

If you are uncertain whether a fact is material, you should give full details so that we can assess its possible significance. If you become aware of such a fact while we are considering your application, you should notify us immediately.

Declaration – by the each applicant

In this declaration, any reference to We refers to either the Company QROPS, QROPS Trustee, QNUPS Trustee or SIPP Trustee whichever is relevant as selected in section B of this form.1. We understand that Quilter International has designated the Policy as suitable only for Professional Investors as defined

by Quilter International in the Policy terms and conditions.2. We confirm that we meet the definition of a Professional Investor. We understand that Quilter International will rely solely

on our confirmation, as part of their application acceptance criteria, that we meet the definition of a Professional Investor.3. We understand that the Policy allows investment into various types of Assets and some of these Assets are only suitable

for Professional Investors. We accept the level of risk associated with these Assets including the risk that the investment into such an Asset: (a) could provide a lower degree of investor protection and regulatory safeguards; and (b) could result in a loss of significant proportion of some or all of the sums invested; and (c) may have a minimum duration, impose significant redemption penalties or are illiquid.

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4. We understand that we should read the offering documents for Assets suitable for Professional Investors. 5. We understand that if we consider ourselves to be a Retail Investor in the future, Quilter International will not restrict the

choice of assets available under the Policy. We also understand that it will be our responsibility to: (a) only choose Assets which are suitable for Retail Investors; or (b) to inform the Fund Adviser that we are now Retail Investors; or (c) to complete a new Investment Mandate and send this to Quilter International where a Discretionary Asset Manager

has been appointed. 6. We understand that we will have an Online Service Account and agree that:

(a) all Policy Transactions will be made by us using our Online Service Account where the Online Service allows, unless we have requested otherwise; and

(b) all communications from us will be through our Online Service Account where the Online Service Account allows, unless we have requested otherwise.

7. For the policy we have requested in Section A, subject to the applicable Terms either:(a) If a bond number is not shown in section A of this form, we request that the amount shown in section E be invested

as an initial premium for the policy we have chosen in section A, and request Quilter International to issue the policy in the name of the trust or the company; or

(b) We request that the amount shown in section E be invested as an additional premium for the policy currently in force bearing the bond number shown in section A of this form.

8. We declare to the best of our knowledge and belief the statements made in this application, and any related documents, are true and complete and that we have not concealed any material fact.

9. WeconfirmthatWearenotresidentorthecompanyisnotincorporatedinHongKong,SingaporeortheUnitedStatesofAmerica or its territories.

10. If We become resident or the company becomes incorporated in the United States of America, Quilter International may not be able to accept any further premiums until after We cease to be resident or the company ceases to be incorporated in the United States of America or its territories.

11. We confirm that the investment into the policy is within the investment powers available to the Trustees under the trust or the company.

12. We confirm that the Company has not been and is not in the process of being dissolved, struck off, wound up or terminated.

13. We confirm that we are applying for an Quilter International policy as instructed by the member. We have received a copy of the Terms and Conditions relating to the chosen policy as indicated in section A and we have had the opportunity to read them when completing this application form.

14. We may wish to invest into professional/non-retail type investment schemes, and if so, we will make sure we have had an opportunity to read the offering documents for funds of this nature. Where we decide to invest in professional/non-retail investment schemes. We accept the levels of risk associated with these, including the risk that the investment into such a scheme could result in a loss of a significant proportion, or the entire sum invested. We also confirm that we are aware of the fees (if applicable) payable for the chosen investment(s) to be held in our policy. We understand that the fees exist partly to meet the promotion and distribution expenses of the product, including commission paid to a financial adviser and or fund adviser.

15. We understand that in cases where the asset(s) we have selected is not redeemable for a certain period of time, Quilter International may not be able to return that part of our payment until the end of that period. The description of the funds and/or assets we have chosen will give details if this applies. We may invest immediately into non-daily dealing funds with the understanding that in the event of cancellation or requiring early access that we: (a) may not get our money back immediately and payment may be delayed for some time;(b) the institution may impose penalties and therefore we may get back less than we invested, and/or(c) the only way in which to receive value may be through an in-specie transfer of that asset into the name of the trust.

16. We are aware of the charges payable on the bond, including the charges payable in respect of the assets which may be held within it. We understand the charges exist partly to meet advice, promotion and distribution expenses. These may include initial and ongoing payments (such as commission) made by Quilter International to our financial adviser. These payments could be in addition to any commission payable by the asset provider to our financial adviser in respect of the assets held. Further details of the charges payable by Quilter International and the amounts payable to our financial adviser are available from our financial adviser on request.

17. We confirm that we are categorised as a professional client in accordance with the UK Financial Conduct Authority COBS 3.5.2 rules.

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Please enter the country in which this application form was completed.This application must be completed by the trustees unless you have asked your financial adviser to complete it.

Did you complete this application form yourself (3)  Yes  No

If No, did a third party, such as your financial adviser, complete it on your behalf? (3)  Yes  No

By signing this declaration you confirm that you have read through the declaration in section L and, if a third party has completed the application form on your behalf, that all the information provided in it is correct.

The QROPS/QNUPS/SIPP Trustees as indicated in Section B (please delete as appropriate)

Name Capacity

Signature DateD D M M Y Y Y Y

Name Capacity

Signature DateD D M M Y Y Y Y

Name Capacity

Signature DateD D M M Y Y Y Y

Copies of the Policy Terms and Conditions and/or this completed application form are available from Quilter International on request.

A copy of the Policy Terms and Conditions for your application are contained on the Quilter International website. Links to these Policy Terms and Conditions are provided below.

Executive Investment Bond

www.quilterinternational.com/globalassets/documentsint/addendums/0397_details_of_your_executive_investment_ bond.pdf

Executive Redemption Bond

www.quilterinternational.com/globalassets/documentsint/t-and-c/1266_details_of_your_erb.pdf

Collective Investment Bond

www.quilterinternational.com/globalassets/documentsint/t-and-c/1204_details_of_your_cib.pdf

Collective Redemption Bond

www.quilterinternational.com/globalassets/documentsint/t-and-c/1265_details_of_your_crb.pdf

Section M – Verification of customer identityIf the QROPS/QNUPS/SIPP trustee currently holds acceptable applicant status, which has been acknowledged by Quilter International, please indicate here. (3)�

If not, please contact Quilter International Isle of Man.

Section N – Financial adviser declarationThis section must be completed in all instances.

Declaration by the financial adviser

I declare that: – I have verified the contents of the original documents where copies have been enclosed and confirm that they are true copies

of the originals. – I have taken reasonable steps to make sure that the funding is legitimate and in line with the member’s circumstances. – To the best of my knowledge and belief, all the information provided in and with this application is true and complete and was

obtained from the member who is of good standing. I also confirm I will provide further information if required. – I have provided the applicant(s) with their Key Information Document where applicable. – I have not made any changes to the application form after the authorised signatories for the company/corporate trustee have

signed it.

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I confirm that I gave advice concerning this investment to the member inon

D D M M Y Y Y Y

I confirm that, if applicable, all information provided was received directly from the member.

Regulatory body authorisation number (if applicable)

Regulator name

Quilter International account numberFull name of introducer firm

Full name of financial adviser

Signature of financial adviser

DateD D M M Y Y Y Y

Financial adviser stamp

9187/INT20-1686/August 2020

www.quilterinternational.com/hk Calls may be monitored and recorded for training purposes and to avoid misunderstandings.

Quilter International is the registered business name of Quilter International Isle of Man Limited Singapore Branch. Quilter International Isle of Man Limited Singapore Branch, CapitaGreen #06-02,138 Market Street, Singapore 048946. Tel: +65 6216 7990 Fax: +65 6216 7999.

Registered in Singapore Number T08FC7158E. Authorised by the Monetary Authority of Singapore to conduct life assurance business in Singapore. Member of the Life Insurance Association of Singapore. Member of the Singapore Finance Dispute Resolution Scheme.

Quilter International’s Hong Kong office: Unit 3704, Lee Garden One, 33 Hysan Avenue, Causeway Bay, Hong Kong. Tel: +852 3552 5888 Fax: +852 3552 5889. Authorised by the Insurance Authority of Hong Kong to carry on long term business.

Quilter International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered Office/Head Office: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Licensed by the Isle of Man Financial Services Authority.

Quilter International is registered in the Isle of Man as a business name of Quilter International Isle of Man Limited.


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